[COMPANY] will accept the signature that appears below as legal and binding only if it is that of a principal or designated principal of the payee. Do not sign this form if you are not a principal or designated principal. This form must be signed by a principal or designated principal.
Under penalties of perjury, I declare that (1) the information provided is true and complete; (2) I am not subject to backup withholding; and (3) I am a U.S. person (or U.S. resident alien).
By typing your legal name and email address in the signature line below you are signing this form electronically and thus you are verifying and authenticating the statements in this submission.
Date* (mm/dd/yyyy) __________